Enhanced Plan SAMPLE. Retirement coverage from Great-West Life

Transcription

1 Enhanced Plan Retirement coverage from Great-West Life

2

3 Table of Contents Section 1: Interpretation and Some Terms Used Interpretation Some Terms Used Section 2: Insurance Provision Section 3: Term of Insurance and Renewability Section 4: Cancellation and Termination Cancellation Termination Section 5: Premium Payment of Premium Receipt for Tax Purposes Change in Premium at Renewal Change in Premium Due to Change in Risk Class Change in Premium Due to Changes to Policies within a Risk Class Change in Premium Due to Other Changes Additional Fees Grace Period Section 6: Covered Healthcare Services and Supplies Payment of Benefits Date of Incurral Definitions Healthcare Services and Supplies Covered by this Policy Section 7: Covered Emergency Travel Medical Payment of Benefits Date of Incurral Definitions Medical Services and Supplies Emergency Medical Assistance Services Courtesy Assistance Services Extension of Coverage Section 8: Limitations General Limitations Specific Limitations for Covered Healthcare Services and Supplies Specific Limitations for Covered Emergency Travel Medical Prelude Enhanced Plan 1

4 Section 9: Exceptions General Exceptions Specific Exceptions for Covered Healthcare Services and Supplies Specific Exceptions for Covered Emergency Travel Medical Section 10: Claim Provisions What to Do in the Event of a Medical Emergency While Traveling Proof of Claim Co-ordination of Benefits Assignment of Rights Against Third Parties Pre-Determination of Dental Accident Treatment Benefits Payment of Claims Overpayment Section 11: Reinstatement Section 12: Surviving Spouse and Children Coverage Section 13: Change in Policy Provisions Section 14: General Provisions Currency Medical and Dental Assessments Misstatement of Age Fraud Payment to Estate Incontestability Conformity to Legislation Section 15: Statutory Conditions Copy of Application The Contract Waiver Material Facts Notice and Proof of Claim Company to Furnish Forms for Proof of Claim Failure to Give Notice or Proof Rights of Examination Limitations of Actions Termination by Insured Termination by Insurer Prelude Enhanced Plan

5 Section 1 Interpretation and Some Terms Used Interpretation The use of capital letters in this policy indicates a term which is defined below or elsewhere in this policy. The use of italicized letters indicates a reference to a heading or sub-heading shown in the Policy Specifications, unless otherwise indicated. Your Policy Specifications list who is covered under your policy, your monthly premium, your policy number and effective date, and information such as your policy s reimbursement levels and benefit maximums. Some Terms Used The following are general terms used throughout this policy. Other terms which are of a more specific nature appear under the heading Definitions in the particular section in which they are used. Acute Care means active intervention required to diagnose or manage a condition that would otherwise deteriorate. Annual Renewal Date means the annual date set out on the Policy Specifications on which Great-West may renew this policy. Application means the form approved by Great-West that the Owner completed and signed in order to apply for the coverage provided under this policy. Covered Emergency Travel Medical means the emergency travel medical services covered by this policy and set out in Section 7. Covered Expenses for Covered Healthcare Services and Supplies and Dental Accident Treatment means the lesser of actual expenses and Customary Charges. Covered Healthcare Services and Supplies means the healthcare services and supplies covered by this policy and set out in Section 6. Customary Charges means the lowest of: representative prices in the area where the treatment was provided; maximum prices established by law; with respect to Covered Healthcare Services and Supplies, prices shown in any applicable professional association fee guide; or with respect to Dental Accident Treatment, prices shown in the Dental Fee Guide for a general practitioner or a specialist fee guide when a specialist provides services within the specialist s specialty. Prelude Enhanced Plan 3

6 Dental Accident Treatment means dental treatment resulting from Injury to a Sound Natural Tooth. Dental Mechanic means a person who is licensed to construct dentures. Dentist means a person, other than an Insured or a member of an Insured s family, who is a licensed dentist in the province or territory or jurisdiction where the dental care is received and who gives dental care within the scope of that license. Government Plan means a plan that provides drug, health, dental or vision coverage and that is legislated, funded, or administered by a government. Group plans for government employees are not included. Great-West means The Great-West Life Assurance Company, and any other companies or persons with whom Great-West may contract to provide, on Great-West s behalf, some or all of the services provided under this policy. Hospital means an institution that: is legally termed a hospital; is open at all times; offers in-patient accommodation; has a staff of one or more Physicians available at all times; and provides continuous 24-hour nursing by graduate registered nurses. Injury means accidental bodily injury. Insurable Child means an unmarried child who at the time of application and while this policy is in force meets all of the following requirements: the child is the natural, adopted, or step child of the Owner or the Insurable Spouse, or a child for whom the Owner or the Insurable Spouse has been appointed guardian for all purposes by a court of competent jurisdiction. the child, if under age 21, is not working more than 30 hours a week, unless the child is also a full-time student. the child, if age 21 or over: is a full-time student under age 25; is incapacitated for a continuous period that began before age 21; or is incapacitated for a continuous period that began while the child was a full-time student under age 25. the child, if the child of the Insurable Spouse, is also the Owner s child or the Insurable Spouse is living with the Owner and has custody of the child. A child for whom the Owner or the Insurable Spouse has been appointed guardian is not insurable unless Great-West has received satisfactory proof of guardianship and if the Insurable Spouse is the guardian, the Insurable Spouse is living with the Owner. A child is considered a full-time student if he or she has been in registered attendance at an elementary school, high school, university, or similar educational institution for 15 hours a week or more sometime in the last six months. If the child is being paid to attend an educational institution, the child will not be considered a full-time student. 4 Prelude Enhanced Plan

7 A child is considered incapacitated if he or she is incapable of supporting him or herself due to a physical or psychiatric disorder. Insurable Spouse means the person who at the time of application and while this policy is in force is the Owner s legal spouse or common-law spouse. A legal spouse means the person lawfully married to the Owner according to the applicable provincial legislation. A common-law spouse means the person who is living with the Owner in a conjugal relationship. Insured means the person or persons named on the Policy Specifications as an Insured. Other Health Insurance Plan means a plan that provides indemnity, insurance, reimbursement or service benefits for hospital, medical, dental, or other types of expenses. Examples of Other Health Insurance Plans include group and individual health insurance coverage, including health benefits payable through an automobile policy, union welfare plan, self-insured group plan, mutual benefit association, prepayment plan or credit card plan. PDAdmin Group means PlanDirect Insurance Services Inc., an agent authorized to perform administrative services on behalf of Great-West or such other party as may be engaged by Great- West to perform such services. Physician means a person, other than an Insured or a member of the Insured s family, who is a licensed medical doctor in the province or territory or jurisdiction where the medical care is received and who gives medical care within the scope of the license. Professional Nurse means a graduate registered nurse, licensed practical nurse, or registered nursing assistant, other than an Insured or a member of the Insured s family. Risk Class means any catagory of Insureds used in Great-West s Risk Classification System for individual health insurance plans of this type. Risk Classification System means the criteria, rules, and procedures used by Great-West to classify risk and to determine eligibility and premium rates for individual health insurance plans of this type, including the variables set out in the Policy Specifications. Sickness means disease or illness. Sound Natural Tooth means any tooth that has not been artificially replaced and that did not require restorative treatment immediately before the Injury. War means an act or state of war, declared or not, and includes any armed conflict by or against any country, political unit or any group formed to engage in war. Written Request means a written request in a form satisfactory to Great-West, together with such evidence satisfactory to Great-West as it may require, if any. Year means the 12-month period beginning on the date that the first expense is incurred. This definition of Year is used for the purpose of determining maximums or frequency limitations, unless the time period is specifically stated as a calendar year. A subsequent Year begins on the date that the first expense is incurred after the end of the previous Year. Similarly, two Years means the 24-month period beginning on the date that the first expense is incurred. A subsequent period of two Years begins on the date that the first expense is incurred after the end of the previous two Years. Other stated periods of Years have a corresponding meaning based on the number of periods stated. Prelude Enhanced Plan 5

8 Section 2 Insurance Provision A person must be covered by the Government Plan providing Medicare coverage in the person s province or territory of residence in order to be eligible for coverage under this policy. No person other than those persons covered under this policy at the Effective Date is eligible for coverage under this policy, except as may be permitted by Great-West according to Great-West s administrative practices at the time. This policy is issued in consideration of the Application and payment of the first premium on or before delivery of this policy. Upon receiving proof of claim satisfactory to Great-West, Great-West will pay benefits for expenses or losses covered under this policy. The expenses must be incurred by the Insured while this policy is in force. For benefits to be payable, Covered Healthcare Services and Supplies must be provided to the Insured as a result of an Injury or Sickness. For benefits to be payable for Covered Emergency Travel Medical: Medical services and supplies must be incurred by an Insured as a result of a Medical Emergency occurring outside Canada; Emergency Medical Assistance Services must be incurred by an Insured as a result of a Medical Emergency occurring outside of Canada or more than 500 kilometres from the Insured s home. Coverage is provided for all Covered Trips that the Insured takes while this policy is in force. There is no limit to the number of Covered Trips any Insured may take while this policy is in force. Payment of benefits under this policy is subject to the limits set out in the Policy Specifications under the heading Healthcare Coverage Limits and Emergency Travel Medical Coverage Limits, the limitations, exceptions and exclusions set out in this policy, and all other provisions of this policy. Section 3 Term of Insurance and Renewability This policy is for a term of one year: commencing on the Effective Date; and ending on the day before the first Annual Renewal Date following the Effective Date. This policy is guaranteed renewable for successive one-year terms commencing on the Annual Renewal Date. The policy must be in force on the day before each Annual Renewal Date in order to be renewed. Great-West reserves the right to change the Annual Renewal Date from time to time. If the Annual Renewal Date is changed, the effect of such a change will be to extend the then-current term of insurance to the day before the new Annual Renewal Date. 6 Prelude Enhanced Plan

9 Section 4 Cancellation and Termination Cancellation Great-West has the right to cancel this policy on any Annual Renewal Date, provided the cancellation will be made to all policies within a particular Risk Class and will not affect only the policy of the individual Owner. Great-West will give written notice of a cancellation to the Owner at least 180 days prior to the cancellation date. Termination This policy will terminate on the earliest of: the date the Owner ceases to be covered under the Government Plan providing Medicare coverage in the Owner s province or territory of residence; the date the Owner ceases to be a permanent resident of Canada; or the last day of the month in which: the grace period ends, if the premium due has not been paid in full by that date; cancellation under the above Cancellation provision occurs; PDAdmin Group receives a Written Request from the Owner to terminate this policy; or the Owner s death occurs. Coverage for an Insurable Spouse or Insurable Child will terminate on the earliest of: the date the Insurable Spouse or Insurable Child ceases to be covered under the Government Plan providing Medicare coverage in their province or territory of residence; the date the Insurable Spouse or Insurable Child ceases to be a permanent resident of Canada; or the last day of the month in which: this policy terminates; the person ceases to qualify as an Insurable Spouse or an Insurable Child; the Insured s death occurs; or the end of the premium period occurs when PDAdmin Group received a Written Request from the Owner terminating coverage for a named Insured. If this policy terminates for any reason set out in the above, any premium which has been paid in advance will be refunded from the first of the month following receipt of written notice of termination. Prelude Enhanced Plan 7

10 Section 5 Premium Payment of Premium The Owner will pay, or cause to be paid, the premium when due. Premiums are due monthly. The first premium is due and payable on or before the Effective Date. Thereafter, each premium is due in advance on the day shown under Premium Frequency on the Policy Specifications. All premiums are payable in advance and must be paid to Great-West. Payment can be made by pre-authorized withdrawal from the account of the Owner, or from the account of the premium payor if other than the Owner. The Owner, or premium payor if not the Owner, may, by Written Request, change the designated account from which payment is to be made. Receipt for Tax Purposes Each year, the Owner will receive a notice showing the portion of the premium that may be available for use in calculating the medical expense tax credit when completing his or her Federal Income Tax return. If this policy terminates during the year, the Owner will receive this notice shortly after this policy terminates. Change in Premium at Renewal Prior to each Annual Renewal Date, Great-West will establish the premium for this policy for the next one-year term based on: the anticipated experience of the Risk Class applicable to this policy; and the attained age, at the Annual Renewal Date, of the oldest Insured in the Risk Class. The new premium will take effect on the Annual Renewal Date of this policy. Any change in premium based on anticipated experience will affect all policies within the Risk Class with the same Annual Renewal Date and not only this policy. Great-West will not change the premium based on anticipated experience more than once in any 12-month period. Great-West will give written notice of a change in premium no less than 31 days before the Annual Renewal Date. This written notice will state the new premium and will be mailed to the Owner at the most recent address shown in Great-West s records. If a change results in a decrease in premium, any excess premium already paid will be applied toward the next premium due. Change in Premium Due to Change in Risk Class The premium will also change if the Owner becomes a member of a different Risk Class. Reasons the Owner may become a member of a different Risk Class include, but are not limited to: a change in the Owner s province or territory of residence; and when coverage is provided for the Owner and the Insurable Spouse and one or the other dies. 8 Prelude Enhanced Plan

11 The Owner must notify Great-West in writing upon the occurrence of any change in an Insured s province or territory of residence and the date the change occurred. The change in premium will be effective on the last day of the month following the date of the change in the province or territory of residence. Change in Premium Due to Changes to Policies within a Risk Class Great-West also has the right to change the premium at any time for any of the following reasons provided that the change will affect all policies within a Risk Class and not only the policy of the Owner: if the introduction, revision, or repeal of a government law or regulation results in a change in the benefits payable under this policy or taxes payable to a government authority; if the benefits payable under this policy are affected by a change in a Government Plan, hospital rates, the Compendium of Pharmaceuticals and Specialties, the Canadian Dental Association Uniform System of Coding and List of Services or similar rate guides approved by the appropriate governing body; or if there is a change in the coverage provided by this policy. Any change in premium for the above reasons will be made to all policies within a particular Risk Class and will not affect only this policy. Written notice of a change in premium will be mailed to the Owner at the most recent address shown in Great-West s records, no less than 31 days before any change in premium becomes effective. The written notice will state the new premium and effective date of the change. If a change results in a decrease in premium, any excess premium already paid will be applied toward the next premium due. Change in Premium Due to Other Changes The premium may also change due to any other change in coverage approved by Great-West after this policy has been issued. A change in premium resulting from a change in coverage approved by Great-West will be effective on the first day of the month following the approval. A change in premium resulting from termination of coverage for an Insurable Spouse or Insurable Child will be effective on the last day of the month following the termination. Additional Fees Great-West may charge a fee for services requested by the Owner and for any payment transaction which is denied because of non-sufficient funds (NSF), in accordance with Great-West s thencurrent fee schedule. Great-West will notify the Owner of the fee and its due date. Grace Period Except for the first premium, a 31-day grace period will be allowed for payment of premium or additional fees not paid when due. This policy will remain in force during any grace period. This policy will terminate automatically on the last day of the grace period if the premium or any additional fees are still unpaid at the end of the grace period, unless otherwise provided. Prelude Enhanced Plan 9

12 Section 6 Covered Healthcare Services and Supplies This section describes the Covered Healthcare Services and Supplies benefits covered by this policy. Payment of Benefits Payment of benefits for Covered Healthcare Services and Supplies will be for Covered Expenses at the Reimbursement Levels shown in the Policy Specifications. Benefits payable are subject to the Healthcare and Emergency Travel Medical Coverage Limits set out in the Policy Specifications. Date of Incurral For the purpose of determining any benefits payable, expenses for Covered Healthcare Services and Supplies are considered to be incurred when the person receives them. For the purpose of determining any benefits payable under the Dental Accident Treatment provision, expenses are considered to be incurred when treatment is completed. Definitions Convalescent Care means active treatment or rehabilitation: for a condition that will significantly improve as a result of convalescent care; and that immediately follows three or more days of confinement for Acute Care. Nursing Home means an institution or that part of an institution that: offers in-patient accommodation; has a staff of one or more Physicians available at all times; and continuously provides 24-hour medical care by or under the supervision of Professional Nurses. For greater certainty, a Nursing Home does not generally include a facility established primarily as a residence for senior citizens or which provides personal rather than medical care. Palliative Care means treatment for the relief of pain in the final stages of a terminal condition. Reasonable Medical Treatment means treatment that: is accepted by the Canadian medical profession; has proven to be effective; and is of a form, intensity, frequency and duration essential to diagnosis or management of the Injury or Sickness. 10 Prelude Enhanced Plan

13 Reasonable Dental Treatment means treatment that: is recognized by the Canadian Dental Association; has proven to be effective; is performed by a Dentist or under a Dentist s supervision, or performed by a Dental Mechanic; and is of a form, intensity, frequency and duration essential to diagnosis or management of dental Injury. Healthcare Services and Supplies Covered by this Policy Unless otherwise indicated, the following services and supplies are covered only when provided in Canada. The services and supplies provided must be Reasonable Medical Treatment for an Injury or Sickness or Reasonable Dental Treatment for an Injury. No benefits are payable for the cost of services and supplies that are not Reasonable Medical Treatment or Reasonable Dental Treatment. Unless otherwise specified, dental treatment is both described and assessed according to the Canadian Dental Association Uniform System of Coding and List of Services, as amended from time to time. Ambulance Services Great-West covers ambulance services, including air ambulance services, if a licensed ambulance company provides them, for transportation to the nearest centre where essential treatment is available. Hospital and Nursing Home Care Hospital Care Great-West covers: semi-private accommodation in a Hospital if: it starts while the Insured is covered under this policy; and it represents Acute Care, Convalescent Care or Palliative Care. the difference between the standard ward rate for the Hospital and the government authorized allowance under the Government Plan in the Insured s home province or territory for Hospital accommodation in Canada but outside the Insured s home province or territory of residence. the Hospital facility fee related to dental surgery for an Insured. charges by a Hospital for services on an outpatient basis, incurred outside the Insured s home province or territory but in Canada when not covered by the Government Plan in the Insured s home province or territory. Nursing Home Care Great-West covers accommodation in a Nursing Home if: the stay starts while the Insured is covered under this policy; the care the Insured receives is Acute Care, Convalescent Care, or Palliative Care; and Great-West has approved the accommodation prior to commencement of care. Prelude Enhanced Plan 11

14 In-Home Nursing Care Great-West covers in-home nursing care if: it starts while the Insured is covered under this policy; it represents Acute Care, Convalescent Care, or Palliative Care; and Great-West has approved it prior to commencement of care. In-home nursing care is care that: requires the skills and training of a Professional Nurse; and is provided in a private residence by a Professional Nurse. The level of skill needed will be determined using applicable licensing restrictions. The Owner must obtain an estimate of nursing care benefits payable under this policy from Great- West. Great-West will require a letter from the attending Physician containing: a description of the Insured s Injury or Sickness; a list of the required nursing services and their frequency; an indication of the level of skill required to perform the required nursing care services, meaning those of a graduate registered nurse, licensed practical nurse, registered nursing assistant, or other practitioner; the number of hours of care required per day or week; and an estimate of the length of time nursing care will be required. Prescription Drugs Great-West covers the following drugs: drugs, including contraceptive drugs and products containing a contraceptive drug, that by law require a Physician or other person entitled by law to prescribe them to be dispensed, according to the Food and Drugs Act, Canada or provincial legislation in effect where the drug is dispensed; drugs that must be injected including vitamins, insulins, and allergy extracts. Syringes for self-administered injections of covered drugs are also covered; disposable needles for use with non-disposable insulin injection devices, lancets and test strips; extemporaneous preparations or compounds if one of the ingredients is a covered drug; drugs that do not require a prescription by law if they are: listed in the current Compendium of Pharmaceuticals and Specialties; prescribed by a Physician or other person entitled by law to prescribe them; and categorized as: a) Antimalarials b) Fibrinolytics c) Muscle relaxants d) Nitroglycerin e) Potassium replacements f) Single entity fluorides g) Single entity iron salts h) Thyroid agents, or i) Topical enzymatic debriding agents 12 Prelude Enhanced Plan

15 Medical Supplies The following medical supplies are covered when prescribed by a Physician. For supplies available on a rental basis, Great-West covers either the rental cost or, at its discretion, the cost of purchase: Breathing Equipment oxygen and the equipment needed for its administration; intermittent positive pressure breathing machines; continuous positive airway pressure machines; apnea monitors for respiratory dysrhythmias; mist tents and nebulizers; chest percussors, drainage boards, and sputum stands; suction pumps; and tracheostoma tubes. Orthopedic Equipment braces - wearable, orthopedic appliances that rely on a rigid material such as metal or hard plastic to hold parts of the body in the correct position. Elastic supports and foot orthotics are not considered braces; cervical collars; casts; splints, including shoes attached to a splint; external electrospinal stimulators for the correction of scoliosis; non-union bone stimulators; and prone standers. Prosthetic Equipment artificial eyes, including rebuilding and polishing of artificial eyes; standard artificial limbs, including repairs, stump socks, and shoulder harnesses; cleft palate obturators; external breast prostheses; surgical brassieres; internal breast prostheses to the amount payable for external breast prostheses; and myoelectric arms, including repairs. Mobility Aids wheelchairs and power scooters when necessary to permit independent participation in daily living; repairs and rechargeable batteries for covered wheelchairs; mechanical or hydraulic patient lifters; and outdoor wheelchair ramps. Prelude Enhanced Plan 13

16 Diabetics Supplies blood-glucose monitoring machines. Hearing Aids hearing aids, including batteries, tubing and ear molds provided at the time the hearing aid is purchased; and hearing aid repairs and adjustments. Other Medical Supplies canes, walkers, crutches and parapodiums; hospital beds, bed rails, trapeze bars, head halters, and traction apparatus; colostomy and ileostomy supplies; catheters and catheterization supplies; food substitutes that must be administered through a tube feeding process. Tube feeding pumps and pump sets are also covered; transcutaneous nerve stimulators for the control of chronic pain; custom-made pressure supports for lymphedema; extremity pumps for lymphedema or severe postphlebitic syndrome; custom-made graduated compression hose; custom-made burn garments; elevated toilets seats, shower chairs, bathtub rails, and standard commodes; wigs for cancer patients undergoing chemotherapy; surgically implanted intraocular lenses; and eyeglasses or contact lenses following eye surgery. Diagnostic Services Great-West covers diagnostic laboratory and x-ray procedures performed in the Insured s province or territory of residence when coverage is not available under the Insured s Government Plan. Paramedical Services Unless prohibited by law, Great-West covers the portion of the cost of the following paramedical services that is not payable under a Government Plan, when provided out-of-hospital: treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor; treatment by a licensed osteopath, including diagnostic x-rays; treatment of movement disorders by a licensed physiotherapist; treatment of foot disorders, including diagnostic x-rays, by a licensed podiatrist; treatment by a registered psychologist or social worker; treatment by a qualified massage therapist; treatment of speech impairments by a qualified speech therapist; treatment by a licensed naturopath; and treatment by a qualified acupuncturist. 14 Prelude Enhanced Plan

17 Dental Accident Treatment Dental Accident Treatment is covered if is required as a result of a blow from an external force: the Injury occurs while the Insured is covered under this policy; treatment is performed by a Dentist, oral surgeon or Dental Mechanic; and treatment begins within 60 days after the Injury. This requirement will be waived if Great-West receives satisfactory evidence that an Injury or Sickness has delayed treatment beyond 60 days. Section 7 Covered Emergency Travel Medical Important notice please read carefully before travelling The Covered Emergency Travel Medical provision covers losses arising from sudden, unexpected and unforeseeable circumstances. It is important to read and understand this policy before travelling as coverage may be subject to certain limitations and exceptions. If you have any questions about this coverage, please call The Great-West Life Assurance Company Individual Health Unit at Each Insured must have Government Plan coverage to be eligible for coverage under this policy. It is important to review the Government Plan coverage before traveling to ensure there is sufficient insurance. The Government Plan coverage may have time limits on submitting claims that would also apply under this policy. An exception may apply to medical conditions and/or symptoms that existed prior to a Covered Trip. Read this policy to determine if this applies and how it relates to each Departure Date or Effective Date. In the event of an Injury or Sickness, the Insured s prior medical history will be reviewed when a claim is reported. This policy provides travel assistance. An Insured is required to notify the Assistance Centre prior to treatment. This section describes the Covered Emergency Travel Medical benefits covered by this policy. Payment of Benefits Payment of benefits for Covered Emergency Travel Medical will be for Covered Expenses at the Reimbursement Levels shown in the Policy Specifications. Benefits payable are subject to the Healthcare and Emergency Travel Medical Coverage Limits set out in the Policy Specifications. Prelude Enhanced Plan 15

18 Date of Incurral For the purpose of determining any benefits payable, expenses for Covered Emergency Travel Medical are considered to be incurred when the person receives them. Definitions Assistance Centre means the network that provides 24-hour telephone emergency medical assistance services and courtesy assistance services on behalf of Great-West. This network assists in locating emergency medical and dental care, and obtaining Great-West s prior approval for medical services and supplies and assistance services, where required. Assistance services are described in the Medical Services and Supplies, under Emergency Medical Assistance Services and Courtesy Assistance Services. Covered Trip means: for the purpose of Emergency Medical Assistance Services, the first 90 consecutive days during which the Insured is absent from Canada or is traveling more than 500 kilometres from home, while this policy is in effect; and for the purpose of Emergency Medical Treatment, the first 90 consecutive days during which the Insured is absent from Canada, while this policy is in effect. A Covered Trip must begin and end in Canada. Departure Date means the date an Insured leaves on a Covered Trip. Emergency Medical Treatment means medical treatment immediately required for the relief of an Injury or an acute episode of Sickness. Emergency Medical Assistance Services means the emergency assistance services described under Medical Services and Supplies. Extended Family means the child, spouse, parent, guardian, brother, sister and grandparent of the Owner or the Insurable Spouse. Medical Emergency means: any sudden, unexpected Injury; an acute episode of a Sickness that did not present signs or symptoms or was not being treated prior to the Insured s Departure Date from Canada; or an unexpected and unforeseen acute episode of a Sickness that was a previously identified medical condition that was stable and controlled on the Insured s Departure Date and which requires Emergency Medical Treatment. For the particular medical condition to be considered stable and controlled, in the three months (pre-travel period) prior to an Insured s Departure Date: the Insured s medical condition must not have worsened; the Insured must have consistently been taking medications, as prescribed by the Insured s Physician, if any; the Insured s Physician must not have prescribed or recommended any medical, surgical or diagnostic procedures for the Insured; and 16 Prelude Enhanced Plan

19 the Insured must not have had any new treatments or medications, or changes in dosages. For this purpose, the following will not be considered to be new treatments or medications: a change from a brand-name medication to a generic brand medication; a new medication prescribed because a drug manufacturer has discontinued the original medication; aspirin taken for non-prescribed medical purposes; vitamins and minerals and non-prescription medications; or creams or ointments prescribed for cutaneous irritations and the following will not be considered to be changes in dosage: the routine adjustment of insulin or coumadin; a decrease of the dosage of cholesterol medication; or a dosage change of thyroid or homone replacement therapy medication. A Medical Emergency ends on the earlier of the date when the Insured is no longer receiving Emergency Medical Treatment or the attending Physician has confirmed that the Insured s medical condition has improved or stabilized to the extent of allowing the Insured to travel. Non-Emergency Treatment or Surgery means: any treatment or surgery not required for immediate relief of acute pain or suffering or which could reasonably be delayed until the Insured returns home, including periodic check-ups or examinations and regular care for chronic conditions; any treatment received by the Insured outside of Canada following Emergency Medical Treatment, including follow-up visits and rehabilitation, if the Insured s medical condition permits the Insured to return home; any treatment or surgery for a medical condition where the medical condition would not have prevented the Insured from returning home for treatment or surgery; and any medical or Hospital services which the Insured specifically traveled to obtain, whether or not on the advice of a Physician. Medical Services and Supplies The following services and supplies are covered when provided during a Covered Trip. The provision of these services and supplies must be related to Emergency Medical Treatment resulting from a Medical Emergency. Emergency Medical Treatment Ambulance Services ambulance services, including air ambulance, to the nearest centre where essential treatment is available. where air ambulance service is required, coverage for a medical attendant is also included, if required. Air ambulance services must be approved, in advance, by Great-West and arranged by the Assistance Centre. Prelude Enhanced Plan 17

20 Hospital Services Hospital in-patient services and supplies, including room and board and general nursing care while confined to a Hospital semi-private room, ward, coronary care unit or intensive care unit for Acute Care; surgery; and Hospital outpatient services and supplies. Physician Services the services of a Physician. Emergency Dental Treatment emergency dental treatment provided for treatment to a Sound Natural Tooth. Private Duty Nursing Services the services of a Professional Nurse when provided during Hospital confinement for Emergency Medical Treatment, and ordered by a Physician. Miscellaneous Services and Supplies The following miscellaneous services and supplies are covered when provided on an in-patient or out-patient basis: anaesthesia and its administration; diagnostic X-ray and laboratory examination; whole blood, blood plasma and blood products; oxygen and its administration; casts, dressings, crutches, canes, slings and splints; prescription drugs requiring a prescription by law; and rental of medical appliances, a hospital-type bed, wheelchair, crutches, braces (not to exceed the cost of purchase). Emergency Medical Assistance Services Where Great-West has given its prior approval, Great-West will pay for, or reimburse expenses for, Emergency Medical Assistance Services resulting from a Medical Emergency, when arranged by the Assistance Centre. Medical Evacuation and Repatriation transportation to the nearest Hospital where treatment is available or to a Hospital in Canada; and coverage for a medical attendant, if required. Great-West reserves the right to request the Insured to transfer to another Hospital or return the Insured to his or her home province or territory. Great-West will have no further liability for that Medical Emergency if the transfer request is refused. 18 Prelude Enhanced Plan

21 Return Home Return home by an Insured by economy seating (or by upgraded seating or air ambulance if medically necessary), as well as additional seats for a stretcher, if required. If an Insured is hospitalized and unable to accompany home any other Insured who is on a Covered Trip with the Insured, a one-way economy flight for each such Insured to return home. Return or round trip transportation for an attendant for any Insured who is unable to travel alone when considered necessary by Great-West. Extended Stay If the Insured is unable to return to his or her home province or territory by the originally scheduled date of return because the Insured is hospitalized on that date, any unexpected additional hotel accommodations and meals incurred by the Insured, and by a person who accompanied the Insured on the Covered Trip and who wishes to stay with the Insured or at the bedside of the Insured. Coverage begins on the day after the originally scheduled date of return. Identification of Deceased Insured In the event of the death of an Insured during a Covered Trip, reasonable travel, hotel accommodation and meal expenses for one person to identify the remains. Repatriation of Deceased Insured In the event of death of an Insured during a Covered Trip, the cost of services and supplies legally required for the preparation of the body and the cost for its return transportation to Canada. Burial or Cremation of Deceased Insured at the Place of Death In the event of death of an Insured during a Covered Trip, the cost of services and supplies legally required for the preparation of the Insured s body for burial or cremation at the place of death. Transportation to Bedside If the Insured is on a Covered Trip alone, is hospitalized and expected to remain in Hospital for more than seven consecutive days, the cost for reasonable travel, hotel accommodation and meal expenses for one person to visit the Insured. Vehicle Return If, for medical reasons, an Insured or any accompanying person is unable to drive an automobile owned or leased by the Insured to his or her home or to the place to which the automobile must be returned, the cost of returning the automobile. Prelude Enhanced Plan 19

22 Courtesy Assistance Services The Assistance Centre will provide the following courtesy assistance services to an Insured by way of a toll-free telephone number, 365 days a year, 24 hours a day: referrals to help locate appropriate medical care; assistance in contacting the family, employer, Physician or other medical professional; assistance in obtaining a second opinion if the Insured has doubts about his or her medical treatment or progress; assistance in arranging payments or payment guarantees to medical facilities and transfers of funds; confirmation to medical facilities of insurance coverage; assistance in locating legal assistance; telephone interpretation services; assistance in replacing lost or stolen travel documents and recovering misdirected luggage; and assistance with the transmission of urgent messages, emergency travel arrangements and other details. Extension of Coverage Involuntary Extension If an Insured s return is delayed beyond the scheduled date of return to his or her home province or territory, due to: a delay in the means of transportation by the scheduled carrier; or inclement weather or vehicle mechanical problems, if the Insured is driving and had commenced his or her return trip before the delay, coverage is extended automatically for up to a maximum of 72 hours without additional premium, provided this policy is in force at the time of the delay. Extension of Medical Benefits If an Insured is still confined in a Hospital as a result of a Medical Emergency on the date coverage under this policy ends, Great-West will continue to pay for expenses otherwise covered under this policy and incurred in connection with the Medical Emergency for which the Insured was hospitalized, until the date the Medical Emergency ends. If, as a result of Emergency Medical Treatment or Emergency Medical Assistance Services, an authorized evacuation or transportation service is delayed beyond the date coverage under this policy terminates, Great-West will continue to pay for expenses otherwise covered under this policy until the completion of the transportation or evacuation trip. 20 Prelude Enhanced Plan

23 Section 8 Limitations General Limitations For Covered Healthcare Services and Supplies and Covered Emergency Travel Medical, benefits payable are per Insured person, unless otherwise indicated. Benefits payable for Covered Healthcare Services and Supplies and Covered Emergency Travel Medical eligible under any Government Plan are limited to any deductible and co-insurance amounts the Insured is required to pay under the Government Plan. The Maximum Benefit Amount payable for Covered Healthcare Services and Supplies and Covered Emergency Travel Medical for all expenses incurred for one Insured is set out in the Policy Specifications. Benefits payable under this policy are further limited as set out below. Specific Limitations for Covered Healthcare Services and Supplies Hospital and Nursing Home Care Hospital Care For accommodation in a Hospital, benefits payable are limited to the difference between the Hospital s semi-private and standard ward rates up to $225 per day for a maximum of 90 days per Insured in a calendar year. Nursing Home Care For Nursing Home accommodation, benefits payable are limited to the government-authorized co-payment under the Government Plan providing coverage in the Insured s home province or territory for a maximum of 30 days per Insured in a calendar year. In-Home Nursing Care Benefits payable for in-home nursing care are limited to the minimum number of hours per day or week and level of skill needed to provide essential nursing service. Benefits payable for in-home nursing care are payable for a maximum of 12 months, beginning on the first day of care. The maximum amount payable is $25,000. The maximums will be reinstated for a subsequent period of in-home nursing care if: it follows a period of at least six months during which no nursing care was needed; or it is required for a different and unrelated Injury or Sickness. Benefits for Hospital care and in-home nursing care are not payable for chronic conditions. Prelude Enhanced Plan 21

24 Prescription Drugs Benefits payable are limited to any single purchase of a drug that would reasonably be consumed or used within 34 days, except for the following maintenance drugs when dispensed in quantities that would reasonably be consumed or used within 100 days: antiasthmatics cardiac agents antibiotics for acne estrogens anticoagulants glaucoma anticonvulsants hypoglycemic agents antihypertensive agents potassium replacements antiparkinson thyroid preparations. antituberculosis Benefits payable for interchangeable products are limited to the cost of the lowest priced item in the applicable drug category, unless the prescription has been written by brand name and directed by the prescriber not to be interchanged. If it has, the actual expense will be considered eligible for payment as long as the prescription bears the notation DO NOT PRODUCT SELECT, NO SUB, or NO SUBSTITUTION on the actual script in the prescriber s own handwriting. Benefits payable for the ingredient portion of the prescription drug charge are limited to the average wholesaler s price plus a reasonable mark-up based on prevailing market conditions. Prosthetic Equipment Benefits payable for the following are limited to a combined maximum of $10,000 every three Years: artificial eyes, including rebuilding and polishing of artificial eyes; standard artificial limbs, including repairs, stump socks, and shoulder harnesses; and cleft palate obturators. Benefits payable for myoelectric arms, including repairs, are limited to $10,000 per prosthesis. Coverage for internal breast prostheses is limited to the amount payable for external breast prostheses. Coverage for external breast prostheses is limited to once in a calendar year for each breast. Coverage for surgical brassieres is limited to twice in a calendar year. Mobility Aids Where the Insured has been reimbursed for a power scooter, no benefits are payable for the purchase of a wheelchair until at least three Years have elapsed since the power scooter was purchased. Benefits payable for wheelchairs are limited to $10,000 every three Years. Benefits payable for mechanical or hydraulic patient lifters are limited to $2,000 every five Years. Benefits payable for outdoor wheelchair ramps are limited to $2,000 in an Insured s lifetime. 22 Prelude Enhanced Plan